Journal of Otolaryngology-ENT Research Review Article Open Access Steroid therapy for nasal polyp: compliance due to cost and phobia in developing countries Abstract Volume 10 Issue 6 - 2018 Nasal polyps are among the common conditions encountered by an otolaryngologist in Vadisha Srinivas Bhat routine clinical practice. It is a benign lesion, but can be troublesome due to variety of Department of Otorhinolaryngology, Deemed to be University clinical symptoms. A condition, which can be diagnosed easily by clinical examination K S Hegde Medical Academy, India supported by CT scan of the paranasal sinuses, poses a challenge in the treatment. While surgical clearance with the aid of endoscopic sinus surgery can provide quick Correspondence: Vadisha Srinivas Bhat, Professor, relief from nasal obstruction, it is frequently followed by recurrence. Medical treatment Otorhinolaryngology, K S Hegde Medical Academy, NITTE, with systemic and intranasal steroid is increasingly used with success as reported by Deemed to be University, Mangalore 575018, Karnataka, India, many authors around the world. Steroid has been used as a single modality of therapy Tel +919480174828, Email or as an adjuvant to surgical therapy before and after the surgery. Considering the long duration of treatment required with intranasal steroids, a large proportion of patients Received: July 06, 2018 | Published: November 16, 2018 discontinue the treatment after certain period of usage, due to number factors which include the cost of therapy and phobia of steroids. This is a review about the steroid usage in nasal polyp, with emphasis on the compliance. Keywords: nasal polyp, steroid; phobia, cost, compliance Introduction sinusitis, whereas allergic fungal sinusitis causes multiple bilateral nasal polyps. Katzenstein et al.3 described the case histories of seven Nasal polyps are benign lesions arising from the mucosa of the patients with asthma, nasal polyposis, sinusitis and allergic mucin nasal cavity or the paranasal sinuses. It is a clinical manifestation of within sinuses. This allergic mucin contained laminated mucin, some of the mechanisms that is present in few people. The prevalence eosinophils, Charcot-Leyden crystals, and fungal hyphae. They called 1 of nasal polyposis ranged from 1% to 4.3%. Presentations of nasal this condition as “allergic aspergillus sinusitis”.3 Later, de Shazo et al polyps is usually after the age of 20 years. It is very rare in children. proposed diagnosed criteria for allergic fungal sinusitis.4 Common symptoms of nasal polyps are nasal obstruction, increased nasal secretion, hyposmia or anosmia, postnasal drip with resultant Cystic fibrosis, Aspirin (ASA) intolerance, Young’s syndrome, cough and sleep disturbance. When the polyps become larger, they Churg strauss disease, primary ciliary dyskinesia are few uncommon obstruct the sinus ostium, causing secondary sinusitis. Some patients associations of nasal polyps. Samter’s triad or ASA triad is the present with a visible mass in the nasal cavity with a fear of having syndrome of nasal polyposis, asthma and ASA intolerance. This triad a tumour, after ignoring initial symptoms of nasal obstruction and has been found in 8-39% of patients with nasal polyps.5 As many discharge. Epistaxis is a rare symptom in nasal polyp, but can occur as 10% of children with cystic fibrosis may have concomitant nasal due to secondary rhino sinusitis, when the polyp is longstanding. Even polyps.5 though a simple disease, this can significantly affect the quality of life Diagnosis of the affected person. Most of the cases of nasal polyp can be easily diagnosed with Etiology of nasal polyp clinical examination alone. Anterior rhinoscopy will reveal multiple Exact etiology of nasal polyp is unknown; however it is associated pale, oedematous mass which are generally bilateral (Figure 1). Nasal with many other conditions. Factors considered in the pathogenesis mucosa is hyperaemic with various stages of oedema. Sometimes of nasal polyp are chronic rhino sinusitis, family history and genetic posterior rhinoscopy or nasal endoscopy is needed to investigate the predisposition, atopy and allergy to inhalant and food allergens and origin of the polyp. Smaller polyps limited to the middle meatus, aerodynamic factors.2 ethmoidal bulla, frontal recess, and uncinate process are can be seen endoscopically. Mucus or purulent postnasal drip is often present in Allergy is the most common association of nasal polyp. Elevated the pharynx.2 IgE levels in these patients, and the response to steroid therapy, supports this theory. Asthma is associated with 25% to 32.6% of patients with nasal polyps.1 Asthmatic patient have a twofold higher risk for having nasal polyps than individuals without asthma; however, polyps are more common in patients with nonallergic asthma compared with those with allergic asthma suggesting that bronchial asthma rather than allergy may be a predisposing factor.1 Nasal polyps are present in both atopic and nonatopic Individuals. Chronic rhino sinusitis is another cause for nasal polyposis. Antrochoanal polyps have been associated with bacterial rhino Figure 1 Specimen of nasal polyp. Submit Manuscript | http://medcraveonline.com J Otolaryngol ENT Res. 2018;10(6):312‒316. 312 © 2018 Bhat. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and build upon your work non-commercially. Copyright: Steroid therapy for nasal polyp: compliance due to cost and phobia in developing countries ©2018 Bhat 313 Plain X-rays of the paranasal sinuses are almost obsolete now. CT lamellar element.7 Tissue eosinophilia is a general character of nasal scan of nose and paranasal sinuses will show the extent of nasal polyp, polyps and is found in 80-90% of all cases.1 Most nasal polyps are changes in the sinuses and anatomical variations, which are important characterized by significant eosinophil accumulation compared with considerations if surgical treatment is planned. Coronal CT is the nasal mucosa from the same patients or from healthy individuals or standard view, which provides the required information in most of patients with allergic rhinitis. However, antochoanal polyps seem to the cases. Axial view may be required in some cases, especially those have different cellular content, with a predominance of neutrophils with complications. The most important advantage of CT scanning and almost an absence of eosinophils. Polyps from both atopic and is the precise view of the sinuses and ostiomeatal complex.2 Nasal nonatopic patients have similar cellular profiles, with activated polyposis will be seen as homogenous soft tissue opacity in the nasal eosinophils, mast cells, and T cells, but they are different from polyps cavity and involved paranasal sinuses (Figure 2). In case of allergic in patients with cystic fibrosis or antrochoanal polyposis.2 fungal sinusitis, there will be heterogenous soft tissue opacity within the sinuses (Figure 3). Several staging methods have been described Treatment for assessment of the degree of inflammatory changes in paranasal Nasal polyposis can be a frustrating disease for the patient and sinuses on CT scan, the most commonly used is the Lund-Mackay for the treating physician. Management of nasal polyps comprises a 6 system. combination of medical and surgical therapies. The recurrence of nasal polyposis constitutes a serious clinical problem. Recurrence rates up to 40-60% have been reported.8–10 These are used as either a primary treatment or following surgery, to prevent recurrence. Steroids have a multifactorial effect initiated by their binding to the cytoplasmic glucocorticoid receptor cell. The number of glucocorticoid receptors is reduced by glucocorticoid treatment.11 Myers reported cases with intranasal injection of corticosteroids with complete regression of the polyp in few cases, and partial regression in large number of patients. He advocated the use of repeated injections of steroid into the polyp and concluded this method is very useful in patients where surgery need to be avoided.12 Intranasal injections is not a routine practice now; instead steroid preparations are used most commonly as nasal spray or drops, and sometimes systemically. A short course of oral steroid followed by intranasal steroid spray can significantly reduce the nasal polyp, at times complete regression (Figure 4) & (Figure 5). Topical steroids have been investigated extensively. In all patients the addition of simple saline nasal douche for cleaning the nose prior to topical Figure 2 CT scan Nose and Paranasal sinus, showing an Antrochoanal polyp in right nasal cavity. medications is beneficial, as these irrigations have been shown to improve nasal mucocilliary clearance.13 Figure 3 Heterogenous opacity seen in a case of allergic fungal sinusitis with bilateral nasal polyposis. Pathology of nasal polyps Nasal polyps are lined by a pseudostratified ciliated columnar epithelium, thickening of the epithelial basement membrane, scanty blood vessels and nerve endings, few glands and goblet cells. The stroma contains eosinophils, neutrophils, lymphocytes, monocytes, Figure 4 CT scan of a patient with bilateral nasal polyp (before treatment). plasma cells, mast cells and macrophages. Mast cells occur about twice as frequently in nasal polyps as in the normal nasal respiratory Van Camp C et al.,14 in their 25 patients treated with oral mucosa and they were occasionally found within the surface Prednisolone,